With the political turmoil that exists today, it is difficult to know what direction funding for health care will go. Conservatives at state and federal levels would like to significantly reduce Medicaid and other support programs. On the other hand, liberals are pushing for expanded health care for all Americans. It appears the American voters to not support either of these extremes. This conflict will probably continue as long as health care costs rise which they are expected to do. However, this is only part of the story about health care; let’s take a peek. We’ll discover that the one constant in this field is Change.
Increasing Pace of Change
The rapid pace of change may be the major challenge for health care providers and consumers. There have been significant changes in health care over the past fifty years. Back then many folks did not have any health care coverage and those that did often did not have any or little mental health or substance abuse benefits. Medicare and Medicaid did not exist. Today there is a growing mandate that everyone have some type of insurance and that it include mental health services.
In 2000, Washtenaw County and the University of Michigan formed the Washtenaw Community Health Organization (WCHO) to integrate physical and behavioral health services for community mental health consumers. Other CMH agencies looked askance at this development. While Michigan Medicine and University Hospital supported this project, most of the physical health departments took a hands off approach and “let psychiatry do their thing”. Now, seventeen years later, all CMH agencies have some integrated health services. Today Michigan Medicine’s physical health providers and St Joseph Mercy Health System, who did not want to join the WCHO, are eager to coordinate care with Washtenaw CMH. In addition, the two health systems are partnering to provide coordinated health care. Both are jointly operating Chelsea Community Hospital. Can we hope that in the future all health systems and CMHs will stop competing with each other and partner to provide coordinated care?
New technology is allowing research to move faster and to explore areas never thought possible a few years ago. CMS and other federal agencies have set a goal to get research findings into practice sooner than has occurred in the past however research itself is one of the more competitive professions. Researchers are always competing for name recognition and grant support. Too often projects get labeled “evidenced based” without being replicated in different settings. In the future it will be important to constantly evaluate new research findings and be prepared to implement those that are appropriate. Agencies will need to be flexible and able to make changes quickly. Those that can, providing leadership in new models and funding arrangements will do well.
Change does not come easy or without costs. Staff members are usually comfortable providing services in their traditional manner whereas change requires re-training and learning new interventions. Staff may be threatened and feel that others think they are not providing “good” services. Agencies must be prepared to provide the necessary support including dollars for staff to make changes and handle resistance that will occur.
Change may be even more threatening to consumers. Many consumers are happy with their providers and the services they are receiving. They are most comfortable with what they have vs something new.
The integration of physical and behavioral health care services would appear to be one direction that will continue. Research has shown that persons with serious mental illness die twenty-five years sooner because of the lack of physical health cares. On the other hand, between thirty and forty percent of persons seeking physical health services have a substance abuse or a mental health disorder that often interferes with the care they receive. Studies have shown that when physical and behavioral health services are well integrated, costs do not rise and may even be reduced; however there is no clear model for every community or provider. The unique strengths and weaknesses of health services in a health system and community need to be taken into account when developing new models.
One challenge is getting behavioral health services into primary care settings and getting physical health services to persons with serious behavioral health disorders who usually have difficulty going to primary care clinics. Initial studies show that having a behavioral health provider as part of the primary care team is most effective. This model requires a larger clinic and is not feasible in all settings. Quick consultation and/or intervention by a behavioral health specialist can be effective for other clinics. The referral model that is often used today is least effective.
It is desirable for persons with severe mental health and substance abuse disorders to go to the community for primary care when they are able. Those consumers that are not functioning well enough to go to a community clinic need to receive primary care as part of their service from the community mental health team. Clinical nurse specialists are showing success in providing this care.
Persons with developmental disorders usually have significant physical health issues which require specialist and multiple health care visits. Often their care has not been well coordinated between physical health providers. Behavioral health care is often provided by community mental health agencies and some by other community providers. There is no clear model on how care can be coordinated by the multiple providers these consumers often see. Better coordination would save money and improve care.
Social determinants of health care are factors that affect consumer’s ability to benefit from health care services and drives up costs. It will be important for health systems and providers to develop cooperative arrangements with other resources to assist consumers. Health systems who can achieve this will be leaders in the field.
Funding Health Care; Moving to Value Based
The integration of funding is the most important issue facing policy makers and health care systems. When services are integrated in a cost effective manner, cost shifting will occur. It may be that additional behavioral health services will reduce physical health cost or vice versa. It is essential for funders to provide incentives to providers to incur additional costs and/or loss of revenue. In the past it has been difficult to get either physical or behavioral health providers to voluntarily address this problem. It will probably require finding a new administrative structure/process where all funders and consumers have a voice in making decisions about how funding should occur.
The failure to integrate behavioral health dollars in Michigan has often created significant problems for consumers. HMOs have been responsible to provide care for those with mild to moderate disorder and community mental health agencies for those with severe disorders. Consumers often move between these categories or do not fit neatly into a category that both sides agree upon. Consumers have suffered when either says they should be seen by the other side. A new model must prevent this declining responsibility from occurring. Furthermore, providers will need to have the capacity and funding to serve consumers when their symptoms improve or regress.
The future will bring new models for reimbursing providers. Fee for service based on a fee code encourages overutilization. Providing services or doing procedures that are not necessary occurs. It is natural for providers to desire to maximize revenue. On the other hand, capitated models provide incentives for agencies to limit services especially when budgets get tight. CMS is now encouraging “value-based” models. Friday Facts of August 4th reports on CMS’s desire to explore this model. The challenge here is to find meaningful ways to measure value and quality. Most of these projects have focused on quality measurers for physical health while limited attention has been paid to behavioral health measurers. A value based model will provide an incentive to health care systems to organize services in a manner that provides quality outcomes in the most cost effective way. Reimbursement is not restricted to providing a service that meets a fee code. Providers can be flexible in providing the exact service that an individual or community best needs. Finding new meaningful models is a major challenge. In the near future there will be multiple projects to develop new models for reimbursement. Providers will be challenged to re-organize services to meet the changing reimbursement models which will likely hold them accountable for costs and quality.
Electronic medical records will also have a major impact on improving quality care. Old paper records often created problems. Clinicians did not get their notes written in a timely manner and when they did, the hand writing was often difficult to read and sometimes misread. Records were often lost when being transferred from one clinician to another. Records passed through many hands which put confidentiality at risk. Today any clinician within a digital system who has reason to view a record can do so immediately. The clinician knows what is being done for the patient and how they are responding. The electronic record will know if someone accesses a record without a need to do so. In addition, critical medical information can be shared across health systems. The full electronic record is not shared, only significant information for continuity of care. The challenge is what information needs to be shared and how these systems will be developed and deployed. The availability of this critical information to providers will improve care and reduce costs.
The role of peers will continue to expand as they demonstrate their value as part of a health care team. The role of mentors in AA has long been an important part of a consumer’s recovery. For a number of years Michigan has provided training to certify peers for CMH agencies. CMH agencies have found creative ways for how these consumers can assist other consumers in their recovery. Physical health providers are beginning to involve consumers to provide services. The challenge is to find how consumers can be used and to provide training and oversight for them. More important is reimbursement. Will these individuals be paid staff, volunteers, paid volunteers, or compensated in other ways?
Changing the Structure
Fifty or more years ago, health care services existed in silos. Hospitals stood alone with community doctors having “privileges” to treat their patients there. Doctors were primarily independent working alone in their offices. There were no inpatient beds for mental health patients in the community; these individuals needing hospitalization went to state hospitals or private free standing psychiatric hospitals. Psychiatrists and psychologists primarily used psychoanalysis and saw their patients three to five times a week which limited the number of individuals they could see. There were no social workers, nurses, or others in private clinics or solo practice. There was five or six consultation centers where patients discharged from a state hospital could be seen for medication checks. CMH agencies did not exist. Twelve or more child guidance clinics provided more access to services for children than for adults. It is amazing how things have changed and how services are now available for adults. CMH services are available in every county and organize not only the behavioral health services but the support services needed for persons to live in the community. In the eighties HMOs assumed responsibility for providing physical health and limited mental health services for Medicaid beneficiaries. This was an immediate success in improving access and quality.
Policy makers are still struggling to find a way to bring CMHs and HMOs together, a system where consumer’s care is well coordinated among all of the providers. Financial incentives for providers to do this must be developed. There is still a long way to go. It will be difficult for agencies or individual providers to exist outside a system of care. The future will likely bring more consolidation and larger systems of care.
The first challenge is to bring all of the behavioral health services together in a system to organize care. Is it time for CMH agencies to take on this challenge? The original vision was for CMH agencies to serve all persons in the community who needed behavioral health care. They were diverted from this vision when the priority was to get consumers out of the state hospitals. Patrick Barrie believed that the CMHs had accomplished that goal and that it was time for them to find a new mission and vision.
Why does Medicaid funding have a model where physical health services are contracted to private HMOs and behavioral health services for persons with serious behavioral health disorders to public CMH agencies? What will be the new model that truly brings behavioral health services together with physical health? Could a new model be a “public health system” with an independent Board? This board would then contract with physical and behavioral health providers and ensure that coordination of care would occur and funds used in the most cost effective manner. HMOs and CMHs could each appoint their representatives including consumers. It would be important that behavioral health representatives have an equal voice on the Board and that consumers be well represented. This model has the potential of bringing the strengths of both systems together, each could learn from the other. This would be a challenge to establish but maybe well worth the effort to do.
Fifty years ago folks never imagined or dreamed that so much progress would be made in the delivery of physical and behavioral health care services. There is no doubt that the next fifty years will bring about even more progress than the past fifty. While we can dream about it, we cannot begin to know what the outcome will be; we only know it needs dreaming and action.
This article was originally published at “Connections for Communities that Care” at https://www.macmhb.org//resources/connections.